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外國居民享受避免雙重征稅協定待遇申請表
Application for Treatment Under Double Taxation Agreement
稅務局
To Tax Bureau
一、申請人事項Details of Claimant：
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個人 individual |
姓名Full name |
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國籍 Nationality |
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住所或居所 Domicile or residence |
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郵政編碼 Postcode |
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公司或團體Corporation or other entity |
名稱Name |
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總機構所在地 |
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郵政編碼 |
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Place of Head Office |
Postcode |
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實際管理機構所在地 Place of effective Management |
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郵政編碼 Postcode |
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注冊所在地 Place of registration |
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郵政編碼 Postcode |
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二、所得事項Details of Income：
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股息 Dividends |
支付人名稱 Payer’s name |
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地址Address |
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郵編Postcode |
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支付金額 Amount of payment |
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支付日期 Date of payment |
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利息 Interest |
支付人名稱 Payer’s name |
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地址Address |
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郵編Postcode |
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支付金額 Amount of payment |
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支付日期 Date of payment |
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合同簽字日期 Date of contract |
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合同有效期 Period of contract |
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特許權 使用費 Royalties |
支付人名稱 Payer’s name |
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地址Address |
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郵編Postcode |
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支付金額 Amount of payment |
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支付日期 Period of contract |
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合同簽字日期 Date of contract |
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合同有效期 Period of contract |
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個人勞 務所得 Income of personal service |
職業Profession |
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支付人名稱 Payer’s name |
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地址Address |
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郵編Postcode |
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支付金額 Amount of payment |
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所得項目 Item of income |
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支付日期 Date of payment |
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三、適用的避免雙重征稅協定 Applicable Double Taxation Agreement：
中華人民共和國同 國簽訂的避免雙重征稅協定第 條第 款。
Paragraph ,Article of the Tax Agreement between the People’s Republic of China and .
四、聲明Declaration：
我僅在此聲明以上呈報事項準確無誤。
I hereby declare that the above statement is correct and complete to the best of my knowledge and belief.
申請人簽名或蓋章：
Claimant (Signature of Seal)：
五、申請人居民身份證明（由申請人為其居民的締約國主管稅務機關填寫）：或另附對方主管稅務機關出具的專用證明。
Certificate of Resident Status of Claimant (For the use of responsible tax office of the Contracting state in which the claimant is a resident) or attach the special certificate of resident issued by responsible tax office of the Contracting State in which the claimant is a resident.
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Certification We certify that (claimant’s name)is a resident of according to the provision of paragraph , of Article in the Double Taxation Agreement between and the People’s Republic of China. Claimant’s serial number： Date： Signature or Stamp of tax office |
以下由中國主管稅務機關填寫(The following for the use of responsible tax office of China only)：
編號 （No.）：第 號
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收到申請表日期 Date of receipt of application |
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審核日期 Date of examination |
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審核意見 Examination report |
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主辦人（簽字） Responsible officer (Signature) |
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負責人（簽字） Chief officer (Signature) |
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中華人民共和國國家稅務總局
State Administration of Taxation The People’s Republic of China
